Specialty Medication Reimbursement Specialist

CLS Health PLLC•Webster, TX

13d

About The Position

CLS Health is a growing, physician-led healthcare group in Houston, Texas, focused on holistic, multispecialty care. The Specialty Medication Reimbursement Specialist audits infusion and specialty medication claims to determine what was paid or unpaid and why, then addresses the root causes. The role works with payers, manufacturer programs, and internal billing teams to recover revenue and prevent recurring denials.

Requirements

At least 3 years of experience in medical billing, reimbursement, or revenue cycle, with direct experience in infusion or specialty drug claims.
Working knowledge of J-codes, NDC and unit billing, buy and bill, specialty pharmacy, and medical versus pharmacy benefits.
Ability to read payer policies, fee schedules, and EOBs and explain denials in plain terms.
Experience with copay assistance and manufacturer reimbursement reconciliation.
Comfort with Excel and payer portals.

Nice To Haves

Power BI or reporting experience.
Coding certification, such as CPC or similar.

Responsibilities

Monitor unbilled and unpaid infusion and specialty medication encounters and keep claims moving toward timely submission.
Audit paid claims against expected reimbursement using payer fee schedules and drug allowables, including ASP, WAC, and contracted rates.
Work denials and underpayments and identify causes such as authorization, benefits or site-of-care restrictions, coding or NDC/unit errors, documentation gaps, or unreimbursed copay assistance.
Call payers to confirm coverage, fee schedules, and buy-and-bill versus specialty pharmacy requirements for specific medications.
Reconcile copay card and foundation assistance payments and follow up on outstanding manufacturer reimbursements.
Coordinate corrections and rebills with billing and the intake team, and share findings with intake to help prevent recurring denials.
Report payer- and drug-level profitability and denial trends to the Ancillary Services Manager.